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National Institute on Drug Abuse

Director's Report to the National Advisory Council on Drug Abuse

September, 2000

Research Findings

Research on AIDS and Other Medical Consequences of Drug Abuse

Substance Use and its Relationship to Depression, Anxiety, and Isolation Among Youth Living with HIV

Reductions from lifetime to recent levels of substance use, the time since HIV diagnosis, physical health symptoms, CD4 counts, emotional distress, and social supports were examined among 227 13 to 24 year old (20% female, 80% male) youth living with HIV (YLH). Substance use pervaded the lives of these youth. Male YLH had used more drugs, more often, and for longer periods than female YLH. However, there had been major reductions in use from lifetime to current reports. Being male, having high emotional distress, and having fewer negative social supports were significantly associated with greater reductions in substance use. There was a trend for the length of time that an individual was seropositive being associated with reductions in substance use. The counterintuitive findings suggest that there must be a re-examination of the role of the social support networks of youth living with HIV, as well as the ways in which emotional distress interact with risk behaviors. Rotheram-Borus, M.J., Murphy, D.A., Swendeman, D., Chao, B., Chabon, B., Zhou, S., Birnbaum, J., and O'Hara, P. Substance Use and its Relationship to Depression, Anxiety, and Isolation Among Youth Living with HIV. International Journal of Behavioral Medicine, 6 (4), pp. 293-311, 1999.

Disclosure of Serostatus Among Youth Living with HIV

Disclosure of serostatus and predictors of disclosure were examined among youth living with HIV (YLH). Disclosure patterns, sociodemographic characteristics, sexual and substance-use risk history, and current health status were examined among 350 youth living with HIV aged 13-23 years (27% African-American, 38% Latino; 72% male). In this group 35 had AIDS, 108 were symptomatic, and 201 were asymptomatic. Most youth disclosed their serostatus to family (87%); unexpectedly, young men (93%) were more likely to disclose to friends than were young women (79%). Being younger at diagnosis was significantly more associated with disclosure to family; young men disclosed more often to friends. Most youth disclosed to all their sexual partners (69%); higher rates of disclosure to sexual partners were associated with having fewer partners and being African-American. Condom use was significantly associated with disclosure for young women, and tended to be related to disclosure for young men. Although many YLH disclosed their serostatus to their partners, condom use was not increased. Interventions are needed to increase condom use among YLH, as well as to encourage disclosure to partners by the 30% of YLH who do not disclose. Lee, M., Rotheram-Borus, M.J., and O'Hara, P. Disclosure of Serostatus Among Youth Living with HIV. AIDS and Behavior, 3 (1), pp. 33-40, 1999.

Applications of Ethnography in HIV Epidemiology and Prevention

HIV prevention researchers Clatts and Sotheran have reviewed ways in which ethnography can contribute to public health research targeted to populations of drug-using men having sex with men (DU/MSM). Participant observations were used in specifying the nature and interrelationship between risk practices among DU/MSM. They also show how ethnography can contribute to the process of disentangling the independent effects of age, period, and cohort factors, a perennial problem in epidemiological research in out-of treatment populations. This kind of information is important in developing targeted prevention messages and services, thereby enhancing both the effectiveness of interventions and the efficiency by which prevention resources are utilized. Clatts, M.C., and Sotheran, J.L. Challenges in Research on Drug and Sexual Risk Practices of Men Who Have Sex with Men: Applications of Ethnography in HIV Epidemiology and Prevention. AIDS and Behavior, 4(2), pp. 169-179, 2000.

Cost-Effectiveness Analysis of the National AIDS Demonstration Research Project (NADR), 1987-1992

A study was done by Pinkerton and colleagues from the Medical College of Wisconsin to determine if the NADR program was cost-effective. The original goal of the multisite NADR program was to reduce the sexual and drug injection-related HIV risks of out-of-treatment injection drug users and their sex partners. Previous analyses have established that the NADR interventions were effective in changing participants' HIV-related risk behaviors. In this study, savings in averted medical care costs were compared with the cost of implementing a similar intervention program for injection drug users in eight different NADR locations. The results strongly suggest that the NADR interventions were cost-saving overall, and were, at the very least, cost-effective at all eight sites. In the U.S. and other developed countries, investments in HIV-prevention interventions such as NADR, have the potential to save substantial economic resources by averting HIV-related medical care expenses among injection drug users. Pinkerton, S.D., Holtrave, D.R., DiFranceisco, W., Semaan, S., Coyle, S.L., and Johnson-Masotti, A.P. Cost-threshold Analyses of the National AIDS Demonstration Research HIV Prevention Interventions. AIDS, 14(9), pp. 1257-1268, June 16, 2000.

Focus Group Summaries of High Risk Sexual and Drug-Using Behaviors in Men

The Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research was the basis for 5 sites participating in a research study with a goal of gaining a deeper understanding of the HIV-related risk behaviors and possible intervention strategies for men who have sex with men who are injection drug users and/or crack smokers (referred to as drug-using men who have sex with men or DU/MSM). A Multisite Research Consortium drafted a focus group guide that was led by a facilitator and co-facilitator, at least one of whom was familiar with DU/MSM population in that community. Several common themes emerged from the focus group results across all sites. For DU/MSM, their drug use and drug-related needs are more important determiners of their identity and their behaviors than is their sexual orientation. Many report being alienated or isolated from relationships with others and many of those self-identified as gay report not being part of the local gay community. Participants engage in behaviors which are high risk for HIV, including trading sex for money or drugs, and many report engaging in sex with both men and women. The need for additional services, including services related to HIV prevention and drug treatment, was also identified across sites. The heterogeneity of the DU/MSM community (within and across sites) indicates that a broad range of HIV prevention and other services addressing local needs is required. Rhodes, F., Deren, S., Cottler, L., Siegal, H., Stark, M., and Reich, W. (editors). A Multisite Study of HIV Risks in Drug-Using Men who have Sex with Men: Focus Group Summaries. The University Press, California State University-Long Beach, Long Beach, CA, 2000.

First Injection and Current Risk Factors for HIV Among New and Long-term Injection Drug Users

The purpose of this study was to estimate HIV seroprevalence and to examine the injection and sexual risk behaviors of a cohort of active new heroin injectors who have initiated injection within the past four years and to compare their risk behaviors with those of long-term heroin injectors who initiated injection prior to January 1, 1985. A stratified network-based sample was used to recruit injection drug users (IDUs) from the streets of Miami-Dade, Florida. New IDUs displayed a significantly lower HIV seroprevalence than long-term injectors (13.3% versus 24.7%). Both new and long-term drug injectors exhibited a high level of current HIV risk behavior. While new injectors were more likely than long-term injectors to practice safer injection behaviors at the initial injection episode, the current risk behaviors of new and long-term injectors are similar. Chitwood, D.D., Sanchez, J., Comerford, M., Page, J.B., McBride, D.C., and Kitner, K.R., First Injection and Current Risk Factors for HIV Among New and Long-term Injection Drug Users. AIDS Care, 12(3), pp. 313-320, 2000.

HIV Transmission and the Cost Effectiveness of Methadone Maintenance

Dr. Margaret Brandeau of Stanford University and her colleagues recently published the results of a study in which they found that prevention efforts are more effective when they are targeted to individuals who are centrally located in high-risk networks than when they reach individuals on the periphery of such networks. In this respect, if incremental methadone capacity were targeted to injection drug users who are centrally located in networks, then such expansion would likely be more cost effective than if incremental capacity were located on the periphery of such networks. The paper also concluded that even if methadone maintenance does not lead to a complete or permanent cessation of drug use, it is a cost effective intervention that can play an important role in preventing the spread HIV and improving the length and quality of life for injection drug users and the general population. Zaric, G.S., Barnett, P.G. and Brandeau, M.L. HIV Transmission and the Cost Effectiveness of Methadone Maintenance. American Journal of Public Health, 90(7), pp. 1100-1111, July 2000.

Zinc Status in Human Immunodeficiency Virus Infection

Baum and colleagues recently presented a summary of data on the role of zinc in immune processes such as T-cell division, maturation, and differentiation; lymphocyte response to mitogens; programmed cell death of lymphoid and myloid origins; gene transcription; and biomembrane function. They report that evidence indicates that adequate amounts of zinc are essential to maintain the integrity of the immune system and that HIV-1 infected individuals are a population particularly susceptible to zinc deficiency. On the other hand, excessive zinc may stimulate HIV-1. The association between zinc deficiency and decreased survival in HIV-1 infected individuals indicates the need to carefully consider therapeutic options. Moreover, with the advent of new antiretroviral therapies that may significantly alter the natural history of HIV/AIDS, the prevalence of zinc deficiency and the potential of interventions in HIV-infected individuals may change dramatically, generating new challenges. Baum, M.K., Shor-Posner, G, and Campa, A. Zinc Status in Human Immunodeficiency Virus Infection. Journal of Nutrition, 130, pp. 1421s-1423, 2000.

Trends in HIV Risk Behaviors of N.Y. City IDUs Suggest A Declining Phase of the Epidemic

A study was conducted to assess trends in HIV risk behaviors among IDUs in New York City from 1990 to 1997. IDUs were recruited continuously from a large detox treatment program and a storefront in a drug use area, and were interviewed regarding drug use history, HIV risk behaviors, and participation in a syringe exchange program. Trends were assessed for five risk behaviors in the 6-month period before the interview. The 3 injection risk behaviors (any needle sharing; reusing someone else's injection equipment; and sharing at last injection) declined significantly over time at each site (p<.01). When data were pooled across the sites, all 5 risk behaviors (the 3 injection risk behaviors plus 2 sex risk behaviors: unsafe sex with a casual partner and unsafe sex with a primary partner) declined significantly over time (p>.01). Participation in syringe exchange programs and HIV counseling and testing increased greatly from 1990 to 1997. These findings on trends in HIV risk behaviors among IDUs in New York City indicate a declining phase in the large HIV epidemic. Although the data do not prove that there is a direct causal link between participation in an HIV prevention program and reduced risk behavior, they address the strong possibility. In addition, the findings suggest that it may be possible to reverse large HIV epidemics among persons considered to be at very high risk. DesJarlais, D., Perlis, T., Friedman, S., Chapman, T., et al., Behavioral Risk Reduction in a Declining HIV Epidemic: Injection Drug Users in New York City, 1990-1997. Am J Public Health, 90, pp. 1112-1116, 2000.

IDUs Participating in Syringe Exchange Programs Are More Likely to Quit Sharing Needles

Between 1992 and 1996, researchers recruited 340 high-risk IDUs who reported sharing syringes. The researchers counseled the subjects and tested them for HIV infection twice each year. At a follow-up interview, 60% of the Ss reported having quit syringe sharing. After adjusting for confounding factors, researchers found that IDUs who began using a syringe exchange program (SEP) were 2.68 times more likely to quit than those not enrolled in a program. Those who were already enrolled and continued in an exchange program were 1.98 times more likely to quit sharing needles than those who did not participate. These findings indicate that use of syringe exchange programs can be an important component in reducing the spread of blood-borne infectious diseases among high-risk IDUs. Although political controversy surrounds SEPs, the data suggest they are among the most effective HIV prevention programs for active IDUs. Bluthenthal, R., Kral, A., Gee, L., Erringer, E. and Edlin, B. The Effect of Syringe Exchange Use on High-Risk Injection Drug Users: A Cohort Study. AIDS, 14, pp. 605-611, 2000.

Study Explores Differential HIV Risks Among IDUs, Crack Smokers, and IDUs Who Use Crack

This study was designed to assess differences in sex-related risk behaviors between drug injectors who did not smoke crack cocaine, crack smokers who did not inject drugs, and drug users who both injected drugs and smoked crack. Current drug users (i.e. used within the past 30 days) from 22 cities were recruited and assessed. The sample (n = 26,982) included 28% who injected only, 42% who smoked crack only, and 30% who both injected and smoked crack. Results showed that active drug users were at risk of HIV infection through sexual transmission: in the 30 day period prior to their interview, 28% reported sex with two or more individuals, 23% had an IDU sex partner, and 24% had exchanged sex for drugs or money. In addition, more than 80% did not use a condom during sex. Crack only smokers and crack smoking injectors were more likely than injectors only to report multiple sex partners and exchanging sex. Because of these high-risk behaviors, condom use was of particular importance. The number of days of alcohol use and having an IDU sex partner were independently associated with not using a condom. Crack smoking injectors reported the highest average number of days of alcohol consumption and were the most likely to have had an IDU sex partner. Booth, R., Kwiatkowski, C., and Chitwood, D. Sex-Related HIV Risks Behaviors: Differential Risks Among IDUs, Crack Smokers, and IDUs Who Smoke Crack. Drug and Alcohol Dependence, 58(3), pp. 219-226, 2000.

Street-Recruited Drug Injectors Enter and Remain in Free Methadone Maintenance Treatment

This investigation assessed the treatment entry impact of offering free treatment to street-recruited injecting opioid users, and determined which variables differentiated subjects who entered treatment when it was free, compared to those who entered when they had to pay for treatment. Three hundred and sixty-two out-of-treatment opioid injectors, recruited through street outreach, were randomly assigned to receive or not receive a coupon for 90 days of free substance abuse treatment. Demographics, desire for treatment, drug use and HIV risk behaviors were assessed prior to assignment. Subjects were characterized by frequent and long-term drug use, numerous arrests, a variety of behaviors that placed them at risk for HIV, and ambivalence about entering substance abuse treatment. Offering free treatment led to significantly greater treatment entry (53% vs. 33%) and retention (155 days vs. 83 days). Entry into free treatment was particularly high, compared to those who had to pay for treatment, among persons who had never been in treatment (43% vs. 23%), and those who reported that they did not want to enter treatment (24% vs. 6%). Those who entered free treatment were significantly less likely to have family problems than those who paid for their treatment. Opioid addicts recruited on the street and offered free methadone maintenance treatment are likely to enter and remain in treatment, even if they have never been in treatment before or claim not to want treatment. Different treatment approaches may be necessary if such subjects are motivated more by the removal of financial obstacles than other factors, such as family problems. Kwiatkowski, C., Booth, R., and Lloyd, L. The Effects of Offering Free Treatment to Street-Recruited Injection Opiate Users. Addiction, 95(5), pp. 697-704, 2000.

Study Reports Needle Exchange Does Not Increase Number of Discarded Needles

Researchers estimated the quantity and geographic distribution of discarded needles on the streets of Baltimore during 2 years after a needle exchange program (NEP) opened. Counts were taken of syringes, drug vials, and bottles before the NEP opened and then at 6 periodic intervals for 2 years after it opened, over 32 randomly sampled city blocks. Two years after the NEP opened, there was a significant decline in the overall quantity of discarded needles relative to that of drug vials and bottles (background trash). There was no difference in the number of discarded needles by distance from the program site. The findings suggest that this NEP did not increase the number or distribution of discarded needles. Doherty, M., Junge, B., Rathouz, P., et al. The Effect of a Needle Exchange Program on Numbers of Discarded Needles. Am J Public Health, 90(6), pp. 936-939, 2000.

Qualitative Strategies Provide Fuller Understanding of Social Contexts and Risk Behavior

Researchers applied six qualitative methods in combination with traditional epidemiologic survey approaches and laboratory bioassay procedures to examine neighborhood differences in access to sterile syringes among injecting drug users (IDUs) in three northeastern cities. Methods used included neighborhood-based IDU focus groups to construct social maps of local equipment acquisition and drug use sites; ethnographic descriptions of target neighborhoods; IDU diary keeping on drug use and injection equipment acquisition; ethnographic day visits with IDUs in natural settings; interviews with IDUs about syringe acquisition and collection of syringes for laboratory analysis; and focused field observation and processual interviewing during drug injection. By triangulating findings across the six qualitative methods, researchers were able to examine the effects of local contextual factors on the spread of HIV and other blood-borne infections among injecting drug users and develop better approaches for targeting interventions to specific local settings. Singer, M., Stopka, T., Siano, C., Springer, K., Barton, G., et al. The Social Geography of AIDS and Hepatitis Risk: Qualitative Approaches for Assessing Local Differences in Sterile-Syringe Access Among Injection Drug Users. Am J Public Health, 90, pp. 1049-1056, 2000.

Ethnography May Inform Correlation Between NEP Use and HIV Seroconversion in Montreal

In this article, researchers describe a rapid ethnographic assessment of needle exchange patrons and street youth substance abusers in Montreal in March of 1997 and October of 1998. The ethnographic assessment was designed to collect preliminary participant observation information that could help to explain the disturbing statistical correlation between needle exchange patronage and HIV infection, which was found to occur among IDUs who used the NEP in Montreal from 1989 to 1995. Scenes visited in Montreal were those where cocaine users hustled cocaine and injected the drug. Authors found a disproportionate representation of cocaine injectors among Montreal NEP users, and observed cocaine bingers who injected cocaine repeatedly and rapidly, without regard to whether the syringe was previously used. They also learned that cocaine injectors primarily asked for wider-gauged syringes compared to the thinner needles requested by heroin users. Injectors explained that the plungers on wider syringes slide more easily so they can flush the cocaine into the bloodstream faster, and supposedly get a more intense initial rush. However, wider-gauged syringes retain a greater volume of blood/biomass after use, which increases the risk of infection to those who reuse them. In addition, since cocaine addicts in Montreal often share bags of cocaine on the run, dissolving the cocaine inside the baggie right on the street, they believe they can draw up more solution faster than their companions with the fast-drawing, wide-gauged syringes. The researchers emphasize the importance of complementing quantitative data with qualitative methods to explain significant statistical associations such as the one reported for Montreal's NEPs, and they argue that NEPs by themselves cannot be expected to stem HIV infection in cities where intravenous cocaine use - characterized by compulsive behavior, craving, and multiple HIV risks - is the drug of choice. Bourgois, P. and Bruneau, J. Needle Exchange, HIV Infection, and the Politics of Science: Confronting Canada's Cocaine Injection Epidemic with Participant Observation. Medical Anthropology, 18, pp. 325-350, 2000.

Ethnographic Study Yields Significant Insights on Crack Cocaine Injection in Dayton, Ohio

Crack cocaine injection has become increasingly more common among drug injectors. Researchers in Dayton, Ohio sought to understand this emergent phenomenon by conducting in-depth, qualitative interviews and participant observation with a purposive sample of 16 active crack injectors. Participants were recruited with the assistance of three outreach workers. There were 4 African American women, 3 African American men, 6 White men, and 3 White women in the study. The average age was 43.6. Fourteen of the 16 injectors had also smoked crack in the past 30 days and had been doing so for an average of 6.4 years; 50% of the smokers were daily users. The average age of first injection (mostly heroin) was 25.6 years and the average period of crack injection was 3.7 years. Crack injection does not appear to be a rare practice in Dayton. It seems to have become an attractive alternative to injecting powder cocaine because injectors perceive it to produce a more intense high than powder, to be purer than powder cocaine, to produce a more desirable "boost" when dissolved with vinegar, and to be less harmful when dissolved in lemon juice. This ethnographic study provides insights on how crack cocaine has been integrated into drug-injection lifestyles as a smokeable and injectable substance. Ethnographic monitoring can inform our understanding of the rapid transformation of crack cocaine from a drug that was detested by drug injectors to one that was embraced as an acceptable substance to smoke and/or to inject. Carlson, R., Falck, R., and Siegal, H. Crack Cocaine Injection in the Heartland: An Ethnographic Perspective. Medical Anthropology, 18, pp. 305-323, 2000.

Opiate Inhibition of Chemokine Action

Opiates have been demonstrated to modify immune type cell movement peripherally as well as in the CNS. The simian immunodeficiency virus (SIV)-infected rhesus monkeys are one of the best models for studies related to HIV infection in humans. This group has shown that opiates manifest this action in these monkeys. This is important as a chemokine receptor is key for cell entry of the HIV. In this study, chemotaxis of monkey leukocytes was evaluated using the chemokines interleukin-8 (IL-8) and (RANTES) as the chemoattractants; the effects of various opioid agonists and antagonists on the efficiency of chemotaxis were examined. Opioids were either incubated with monkey leukocytes or added directly to chemokines, and the number of cells migrating toward IL-8 (for neutrophils) or RANTES (for monocytes) was scored. Inhibition of chemotaxis was seen with both assay conditions. Opioids themselves may act as weak chemoattractants for monkey leukocytes; addition of opioid agonists to chemokines appears to reduce the chemoattractant ability of the chemokines. Opioids did not cause the same inhibitory effect on the chemotactic migration of neutrophils when the complement component C5a or the chemotactic peptide N-formyl-MET-LEU-PHE (fMLP) was used as chemoattractant. These studies suggest that the presence of opioids during SIV infection immediately alters chemokine-mediated immune functions. Miyagi, A.U., Chuang, T., Lam, K.M., Kung, H.F., Wang, J.M., Osburn, B.I., and Chuang, R.Y. Opioids Suppress Chemokine-Mediated Migration of Monkey Neutrophils and Monocytes - An Instant Response. Immunopharmology, 47, pp. 53-62, 2000.

Cannabinoid Suppresses Immunity to Legionella Pneumophila

In an effort to study the effects of cannabinoids on opportunistic infections, a mouse model has been established by this group. They have shown that cannabinoids can enhance the deadly effects of Legionella. Herein, they have more clearly defined that a select population of T cells are involved in this disease and have presented findings clarifying the role of the TH1 population of T cells. In the current study, THC effects on cytokines regulating the development of Th1 cells were examined. BALB/c mice showed significant increases in serum IL-12 and IFN-gamma within hours of infection; however, the levels of these Th1-promoting cytokines as well as resistance to a challenge infection were suppressed by THC. The Th2-promoting cytokine, IL-4, was increased within hours of a Legionella infection and was further increased by THC treatment. These results suggested that THC injection suppressed the cytokine environment promoting Th1 immunity. In additional experiments, THC pretreatment and infection of IL-4 knockout mice showed that serum IL-12 and IFN-gamma were suppressed equally in both knockout and normal mice. This suggested that the drug-induced increase in IL-4 was not responsible for the decreases in serum IL-12 and IFN-gamma. However, THC treatment was shown to suppress the expression of IL-12 receptor beta 2 mRNA, indicating that, in addition to suppression of IL-12, THC injection suppressed the expression of IL-12 receptors. Finally, the role of cannabinoid receptors in Th1-promoting cytokine suppression was examined. Results with receptor antagonists showed that both cannabinoid receptors 1 and 2 were involved. It is suggested that suppression of Th1 immunity to Legionella is not due to an increase in IL-4 production but to a decrease in IFN-gamma and IL-12. Furthermore, both types of cannabinoid receptors are involved. Klein, T.W., Newton, C.A., Nakachi, N., and Friedman, H. Delta(9)-tetrahydrocannabinol Treatment Suppresses Immunity and early IFN-gamma, IL-12, and IL-12 receptor beta 2 Responses to Legionella Pneumophila Infection. J Immunology, 164, pp. 6461-6466, 2000.

"Muscle Dysmorphia" in Male Weightlifters: A Case Control Study

In a first ever published controlled study, Pope and his colleagues (McLean Hospital/Harvard) have identified a new diagnostic entity- "Muscle Dysmorphia" among body builders and weightlifters. It is a form of body dysmorphic disorder in which individuals develop a pathological preoccupation with their muscularity. The authors interviewed 24 men (18-30 years old) with muscle dysmorphia and 30 comparison weightlifters, recruited from gymnasiums in the Boston area, using a battery of demographic, psychiatric, and physical measures. Data showed that the men with muscle dysmorphia differed significantly from comparison weightlifters on measures such as body dissatisfaction; eating attitudes; prevalence of anabolic steroids use (45% among muscle dysmorphic men; 6% among comparison weightlifters); and lifetime prevalence of DSM-IV mood, anxiety, and eating disorders. Men with muscle dysmorphia frequently described shame, embarrassment, and impairment of social and occupational functioning in association with their condition. By contrast, ordinary weightlifters displayed little pathology. Indeed, in an a posteriori analysis, the ordinary weightlifters proved closely comparable to a group of male college students recruited as a comparison group in an earlier study. The authors concluded that muscle dysmorphia appears to be a valid diagnostic entity, possibly related to a larger group of disorders, associated with striking and stereotypical features. Men with muscle dysmorphia differ sharply from ordinary weightlifters, most of whom display little psychopathology. Authors recommend research on potential treatment of this syndrome. Olivardia, R., Pope, H.G. and Hudson, A.J. "Muscle Dysmorphia" in Male Weightlifters: A Case Control Study. American Journal of Psychiatry, 157, pp. 1291-1296, 2000.

Body Image Perception Among Men in Three Countries

In another study, Pope and his colleagues (McLean Hospital/Harvard) tested a hypothesis that men in modern Western societies would desire to have a much leaner and more muscular body than the body they actually had or perceived themselves to have. The investigators measured height, weight, and body fat of college-age men in three countries: Austria (n=54), France (n=65) and the United States (n=81). Using somatomorphic matrix, a computerized test, the men chose (i) the body image that they felt represented their own body, (ii) the body they ideally would like to have, (iii) the body of an average man of their age, and (iv) the male body they believed was preferred by women. The men's actual fat and muscularity was compared with that of the four images chosen. Results showed only slight demographic and physical differences among men from three countries. Importantly, in all three countries, men chose an ideal body that was a mean of about 28 lb more muscular than themselves and estimated that women preferred a male body about 30 lb more muscular than themselves. In a pilot study, however, the authors found that actual women preferred an ordinary male body without added muscle. Pope, H.G., Gruber, A.J. Mangweth, B., deCol, C., Jouvant, R. and Hudson, A.J. Body Image Perception Among Men in Three Countries, American J. Psychiatry, 157, pp. 1297-1301, 2000.

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